Author: David Gratzer

Reading of the Week: Suicide Barriers & Suicide Prevention – the New CJP Study; Also, the Future of Education and AI & Diagnoses

November 28, 2024 / / 0 Comments

From the Editor

The idea is simple: if certain locations attract suicidal individuals, making it harder for suicides to occur at those places can help. After much debate, in 2003, the City of Toronto did exactly that, constructing a suicide barrier for the Bloor Viaduct. Suicides immediately declined. 

What has been the long-term effect? And have the means of suicide deaths simply shifted? In the first selection, Dr. Mark Sinyor (of the University of Toronto) and his co-authors attempt to answer these questions. In a new study published in The Canadian Journal of Psychiatry, they drew on over two decades of data to analyze the impact of this suicide barrier. “Contrary to initial findings, these results indicate an enduring suicide prevention effect of the Bloor Viaduct suicide barrier.” We consider the study and its implications.

Pretty but lifesaving?

When it comes to medical education, much has changed over the years – including its name. What was once known as Continuing Medical Education (CME) is now referred to as Continuing Professional Development (CPD). But the changes go far beyond a simple rebranding. After all, the sheer volume of journal articles available today is staggering. How can you keep up? How can technology help? In the second selection, a new Quick Takes podcast, I speak with Dr. Sanjeev Sockalingam (of the University of Toronto) to explore the evolving world of CPD. “It took a pandemic to get us to realize that we could do so much online.”

Finally, in the third selection, from JAMA Network Open, Dr. Ethan Goh (of Stanford University) and his colleagues wonder if AI can assist physicians in making diagnoses. In an RCT, physicians were randomized to either conventional resources or those enhanced by access to AI (specifically, LLM). “In this trial, the availability of an LLM to physicians as a diagnostic aid did not significantly improve clinical reasoning compared with conventional resources.”

DG

Continue reading

Reading of the Week: ED Visits, Hallucinogens & the Risk of Schizophrenia – the New JAMA Psych Study; Also, Alcohol After COVID and Diab on Being Open

November 21, 2024 / / 0 Comments

From the Editor

For my patient who had tried several antidepressants, psilocybin offered hope. He’s not alone; hallucinogens are gaining attention, with many using them for purposes ranging from treating mental disorders to recreation. But how safe are these drugs, especially as their use increasingly occurs outside of clinical settings? What’s the connection with psychosis?

In the first selection, Dr. Daniel T. Myran (of the University of Ottawa) and his co-authors attempt to answer these questions in a new study published in JAMA Psychiatry. The population-based study included over nine million people who had visited an ED in Ontario, Canada over a 13-year period. The researchers compared individuals with an ED visit involving hallucinogen use to the general population and to those with ED visits involving other substances, analyzing the risk of developing a psychotic disorder. “Individuals with an ED visit involving hallucinogen use had a 21-fold greater risk of developing a schizophrenia spectrum disorder compared with the general population…” We consider the study and its implications.

Substance use rose during the early days of the pandemic. Did this trend change after lockdowns and social isolation ended? Dr. Divya Ayyala-Somayajula (of Thomas Jefferson University) and her co-authors analyzed US data related to alcohol use in a research letter for Annals of Internal Medicine. They compared the prevalence of alcohol use and heavy alcohol use before the pandemic, during the pandemic, and in 2020, finding “absolute increases of 2.7% (relative increase, 4.0%) and 1.0% (relative increase, 20.2%) and that the increases were sustained in 2022.”

And in the third selection, writer Saddal Diab discusses her decision to publicly acknowledge her mental disorder. Though people were initially supportive, things changed when she has a manic episode. She considers stigma and acceptance in this Globe and Mail essay. “Whatever gushy feelings had surfaced when I came out did not withstand the reality of mania. This left me feeling ashamed, deserted and questioning the nature of my relationships (which I concluded were flimsier than I had anticipated).”

DG

Continue reading

Reading of the Week: Physician Burnout – the New NEJM Review; Also, Depression in India and Dr. Ushna Shamoon on Bias

November 7, 2024 /

From the Editor

I started watching the clock, thinking about how much time is left in my day. That just started getting earlier and earlier. One day, at 8:35 am, I thought: Oh boy, it feels like I’ve been here a while already.

So comments a colleague on his burnout. 

More and more, we are discussing physician burnout. But how has the concept of burnout evolved over time? How is it distinct from depression? What are evidence-based interventions? Drs. Constance Guille (of the University of South Carolina) and Srijan Sen (of the University of Michigan) seek to answer these questions in a new review for The New England Journal of Medicine. Though they note challenges, including with the definition itself, they strike an optimistic tone. “Over the past 15 years, progress has been made in raising awareness about physician well-being and improving well-being in specific populations, including physicians in training. There is a clear pathway for investing in and implementing established interventions and developing new interventions to improve well-being for all physicians.” We consider the review and its implications.

In the second selection, Dr. Felix Teufel (of Emory University) and his co-authors explore the treatment of depression in India. In a new JAMA Psychiatry brief report, they drew on a national survey, finding limited care, particularly among those living in rural areas. “Nationwide, 97% of individuals with depression were undiagnosed, and around half of individuals with diagnosed depression were untreated.”

And, in the third selection from Academic Psychiatry, Dr. Ushna Shamoon (of the University of Texas) writes about her medical school rotation in a county jail. She discusses her biases before stepping into the correctional facility. She then describes her connection to an inmate suffering from mental illness. “Though her mind was riddled with psychosis, she was not just a victim of her illness.”

Note: there will be no Reading next week.

DG

Continue reading

Reading of the Week: Culturally-Adapted CBT for Postnatal Depression – the New Lancet Study; Also, ADHD in Adults (JAMA Psych) and the Latest in the News

October 31, 2024 /

From the Editor

She was offered CBT through our outpatient program. Though we encouraged her to come, she didn’t even attend one session. Was the problem partly with the rigidity of our program which wasn’t tailored to her cultural background or language? Can we do better? 

Dr. Nusrat Husain (of the University of Manchester) and his co-authors attempt to answer these questions in a new RCT published in The Lancet. In their study, British south Asian women with postnatal depression were randomized to a culturally-adapted form of CBT or treatment as usual. “Participants in the [intervention] group were estimated to be almost twice as likely to have recovered at 4 months than those in the control group.” We consider the paper, the accompanying Comment, and the implications for clinical care.

In the second selection, Drs. Carlos Blanco (of the National Institutes of Health) and Craig B. H. Surman (of Harvard University) write about ADHD for adults. In a new JAMA Psychiatry Viewpoint, they argue that more needs to be done, especially given the adverse outcomes of untreated ADHD. “A tension exists between undertreatment of adults with ADHD and overuse of addictive treatments for the condition.”

Finally, we explore the latest news with recent articles from The Washington Post, The Globe and Mail, and The New York Times. The topics: ChatGPT for psychotherapy, the generosity of Bruce McKean, and the street psychiatry in LA.

DG

Continue reading

Reading of the Week: NMS – the New NEJM Review; Also, Primary Care & Mental Health and Lucy Foulkes on Mental Health Awareness

October 24, 2024 /

From the Editor

I started seeing him after his psychiatrist retired. For the most part, our interactions were unremarkable: quick visits when we would talk about his walks, and then I would offer a prescription. Imagine my surprise when I heard that he had been admitted to the ICU with fever, rigidity, and decreased consciousness.

Neuroleptic malignant syndrome, what my patient developed, is rare and potentially deadly. What’s the DSM description? The differential? What are the implications for future treatment? In the first selection, Drs. Eelco F. M. Wijdicks and Allan H. Ropper (both of the Mayo Clinic Hospital) provide a concise and lucid review for The New England Journal of Medicine. They summarize the literature and offer practical suggestions. “Neuroleptic malignant syndrome is a distinctive and alarming syndrome that occurs in some persons who have been exposed to dopamine-blocking agents, particularly (but not exclusively) antipsychotic drugs.” We discuss the review and its takeaways.

How much of primary care is focused on mental healthcare? In the second selection, Avshalom Caspi (of the University of Oslo) and his co-authors attempt to answer that question, drawing on Norwegian data. In a new study for Nature Mental Health, they analyzed 350 million contacts with primary care (yes, you read that correctly) over a 14-year period. “One out of every 8 or 9 encounters that a primary care physician is for a mental-health concern.”

In the third selection, Lucy Foulkes (of the University of Oxford) writes about mental health awareness efforts. While focusing on the UK, her comments are relevant here, with campaigns by Bell Canada and others. She raises several objections, including that these efforts aren’t matched by improved access to care. “We do not have clear evidence about the impact of mental health awareness efforts. It may be that these efforts are merely a waste of time or that they are actively harmful. Or it may be that despite the above concerns, there is still a net gain that makes the efforts worthwhile.”

DG

Continue reading

Reading of the Week: Care & Technology – Papers on Virtual Care and an App for Alcohol; Also, Dr. Reisman on ChatGPT & Bedside Manner

October 17, 2024 /

From the Editor

With COVID-19, mental health services were transformed in a matter of weeks when much care shifted to virtual. Today, we are all proficient in our webcams and familiar with terms like Zoom fatigue.

From a system perspective, we have unanswered questions: What’s the right amount of virtual care? When is it appropriate? In the first selection, Matthew Crocker (of the Canadian Institute for Health Information) and his co-authors focus on virtual versus in-person follow-up care after an ED visit in Ontario. Drawing on databases, they analyzed more than 28 000 such visits, wondering if the virtual option led to more adverse psychiatric outcomes. “These results support virtual care as a modality to increase access to follow-up after an acute care psychiatric encounter across a wide range of diagnoses.” We consider the paper and its implications.

Apps for mental health are increasingly popular; the mental health app market may be worth more than $24 billion by 2030, according to one estimate. In the second selection from Internet Interventions, John A. Cunningham (of the University of Toronto) and co-authors describe a new RCT involving participants who were concerned about their drinking. 761 were given either an app with several intervention modules or just educational materials. They were then followed for six months. “The results of this trial provide some supportive evidence that smartphone apps can reduce unhealthy alcohol consumption.”

And in the third selection, Dr. Jonathan Reisman, an ED physician, writes about AI. In a provocative essay for The New York Times, he argues that physicians often rely on scripts to seem compassionate – such as when we deliver bad news. AI, he reasons then, could do that well. “It doesn’t actually matter if doctors feel compassion or empathy toward patients; it only matters if they act like it. In much the same way, it doesn’t matter that A.I. has no idea what we, or it, are even talking about.”

DG

Continue reading

Reading of the Week: Antipsychotics – the New, the Old & the Patient Experience, with Papers from JAMA Psych, BJP and Schiz Bulletin

October 10, 2024 /

From the Editor

“FDA approves a novel drug for schizophrenia, a potential ‘game changer’”

– The Washington Post

“Will ‘Game Changer’ Antipsychotic Live Up to the Hype?”

– Medscape

Two weeks ago, for the first time in decades, the FDA approved an antipsychotic for schizophrenia with a novel mode of action. What does the data show for this medication, xanomeline-trospium chloride? Is it a “game changer” as some headlines suggest? 

In the first selection, Dr. Inder Kaul (of Karuna Therapeutics) and his co-authors report on a double-blind, randomized, placebo-controlled trial that was published in JAMA Psychiatry. 256 people with schizophrenia were given the antipsychotic or the placebo and followed for five weeks. “Xanomeline-trospium was efficacious and well tolerated in people with schizophrenia experiencing acute psychosis.” We consider the study and its implications.

In contrast to this week’s first selection, the second selection looks at an older antipsychotic: clozapine. Drawing on Canadian databases, Lloyd Balbuena (of the University of Saskatchewan) and his co-authors put the risks and benefits of this medication in a new light in a paper for The British Journal of Psychiatry. They analyzed data on admissions and adverse events, with almost 50 000 participants. “Clozapine was associated with lower relapse overall, but this was accompanied by higher adverse events for adults. For children/youth, clozapine was associated with lower relapse all throughout and had no difference in adverse events compared with other antipsychotics.”

And in the third selection, Susan Weiner writes about antipsychotics for Schizophrenia Bulletin. She discusses her first psychotic break, her long journey, and her ultimate recovery. In a personal essay, she also describes the connection she made with her psychiatrist and the medication that transformed her life. “The right medicine for the right person can produce sanity like a miracle drug, and all is once again bright.”

DG

Continue reading

Reading of the Week: Ten Great Papers; Also, Mindfulness’s Untapped Potential (JAMA Psych) and the FDA Approves an Antipsychotic (Nature)

October 3, 2024 /

From the Editor

It’s the 10th anniversary of the Reading of the Week. The program has grown and evolved over this past decade, now reaching psychiatrists and residents internationally, but the core idea – timely summaries of the latest in the literature coupled with commentary – hasn’t changed. To mark the anniversary, we look at some important papers that we have covered in the past ten years.

Last week: ten papers that I think about often (and helped change my clinical work).

This week: ten papers that I think about often (and helped change the way I view mental illness).

*      *      *

In the second selection, Jesus Montero-Marin (of the University of Oxford) and his co-authors consider mindfulness-based cognitive therapy in a new Viewpoint for JAMA Psychiatry. Noting the burden of depression, they see this therapy as being helpful, especially for those with “entrenched” depression. “By leveraging translational science, we can enhance access, engagement, and treatment outcomes for depression. This work uses MBCT as a foundational case study and delineates future research directions with the potential to profoundly impact service design and policy.”

And in the third selection, journalist Elie Dolgin reports on the new FDA-approved schizophrenia medication for Nature. He describes the novel mechanism of action and quotes Christoph Correll (of Hofstra University): “This will be a revolution of the treatment of psychosis, and I’m not saying this lightly. Now we will now be able to treat people who haven’t been helped with traditional antipsychotics.”

DG

Continue reading

Reading of the Week: The Readings at 10; Also, Mentorship and Involuntary Care

September 26, 2024 /

From the Editor

10.

This month, the Reading of the Week celebrates its 10th anniversary. The program has grown and evolved over this past decade but the core idea – timely summaries of the latest in the literature coupled with commentary – hasn’t changed. To mark the anniversary, over the next two weeks, we will look at some important papers that we have covered in the past ten years.

This week: ten papers that I think about often (and helped change my clinical work).

Next week: tens papers that I think about often (and helped change the way I view mental illness).

Of course, the lists of papers are hardly exhaustive. Have a favourite that I missed? Please don’t hesitate to email me.

*      *      *

Many of our colleagues speak enthusiastically about the influence of mentors on their lives – but how can you better incorporate mentorship into your career? What should you look for in a mentor? And what exactly is a mentor? In the second selection, we look at a new Quick Takes podcast interview with Dr. Suzanne Koven (of Harvard University). “Mentorship is especially valuable for people who are aspiring to somewhat unconventional careers, and that was certainly the case with me.”

Finally, in the third selection, a Globe and Mail editorial considers substance misuse and Canadian cities. After an episode of violence in Vancouver, they wonder what could be done and weigh more involuntary care for those with substance problems. “Involuntary care has a role to play in some cases. Getting involuntary care right, however, is difficult.”

DG

Continue reading

Reading of the Week: Brief CBT for Suicidal Inpatients – the New JAMA Psych Study; Also, Medicaid & Access, and Dr. Yager on Turning Off the Lights

September 19, 2024 /

From the Editor

After a suicide attempt, he was admitted through our ED. The hospitalization has been helpful: we changed his medications; the family is now more understanding of his problems; he has worked on safety planning with the team. However, could more be offered? It’s a relevant question – particularly for someone like me (I’ve worked on inpatient wards for most of my career).

In the first selection from JAMA Psychiatry, Gretchen J. Diefenbach (of Yale University) and her co-authors describe a randomized clinical trial involving 200 inpatients who received either the usual care or a focused CBT, tailored for short admissions. The one common factor: all participants had had a suicide attempt in the week prior to admission or current suicidal ideation along with a suicide attempt in the past two years. “Brief cognitive behavioral therapy–inpatient reduced 6-month post-discharge suicide reattempts and rate of readmissions when added to treatment as usual.” We discuss the paper and the clinical implications.

Inpatient care: preventing suicide with CBT?

How accessible is mental healthcare in the US? In the second selection, Dr. Diksha Brahmbhatt and William L. Schpero (both of Cornell University) look at Medicaid recipients and psychiatric appointments in a research letter for JAMA. Using a “secret shopper” approach, they contacted clinicians in four cities, trying to book a psychiatric appointment for those covered by the public program. “In the largest Medicaid managed care plans across 4 of the largest US cities, only 17.8% of clinicians listed as in-network for Medicaid were reachable, accepted Medicaid, and could provide a new patient appointment.”

And in the third selection, Dr. Joel Yager (of the University of Colorado), a retired psychiatrist, writes personally in a piece for JAMA. In his later years, Dr. Yager’s father helped his older friends and neighbours with the burden of aging, including visiting them in hospitals when they were ill. Now, he is doing what his father did. “After all, someone has to be around to put out the lights.”

This month, the Reading of the Week celebrates its 10th anniversary. A quick word of thanks for the ongoing interest. I’ll reflect more in the coming weeks.

DG

Continue reading